The decision to intubate

Official reprint from UpToDate® www.uptodate.com

©2024 UpToDate®

The decision to intubate

Author: Calvin A Brown, III, MD
Section Editor: Ron M Walls, MD, FRCPC, FAAEM
Deputy Editor: Michael Ganetsky, MD

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jun 2024. | This topic last updated: May 25, 2023.

INTRODUCTION

The first step in any resuscitation is the verification or establishment of a patent and
protected airway. Emergency defibrillation is the sole, occasional exception to this
principle. Without adequate oxygenation, all other potentially lifesaving maneuvers will
fail. Most often, clinicians secure the airway of an unstable patient through placement of a
cuffed endotracheal tube.

This topic review discusses how to determine the need for intubation and provides a
simple decision tool that is applicable to virtually all emergency patients regardless of age
or presenting condition. Discussions of other aspects of airway management are found
elsewhere.
● (See "Rapid sequence intubation in adults for emergency medicine and critical care".)
● (See "Technique of emergency endotracheal intubation in children".)
● (See "Approach to the failed airway in adults for emergency medicine and critical
care".)
● (See "Approach to the difficult airway in adults for emergency medicine and critical
care".)

DECIDING TO INTUBATE: THREE-QUESTION ASSESSMENT

Emergency clinicians must often perform tracheal intubation under stressful conditions.
Skillful execution of tracheal intubation requires a good understanding of several methods
- Page 1 of 9 -
The decision to intubate

of intubation, how to identify the potentially difficult intubation, the drugs best suited for
airway management in different clinical scenarios, and management of the difficult or
failed airway. Deficiency in any of these areas reduces the likelihood of a good patient
outcome. (See "Rapid sequence intubation in adults for emergency medicine and critical
care" and "Technique of emergency endotracheal intubation in children".)

Even knowledgeable emergency clinicians, however, can contribute to patient morbidity

and mortality by waiting too long to intubate. Inappropriate delays in airway management
can convert a relatively controlled opportunity to secure the airway into a hectic,
unplanned situation ("crash" airway), eliminating the opportunity for a well-prepared,
methodical approach. As examples, clinicians should not postpone intubation until the
patient with anaphylaxis develops stridor or wait for worsening of hoarseness in the
patient with smoke inhalation.

The decision to intubate can be obvious and require little deliberation, as with the
comatose head-injured patient who requires immediate intubation. It may also be clear
when intubation can be withheld, such as the patient in mild respiratory distress from
acute heart failure who is rapidly improving with nitroglycerin and noninvasive positive-
pressure ventilation (NIPPV). Between such cases lies a range of airway management
scenarios where the need for tracheal intubation may be unclear. When confronting such
scenarios, the emergency clinician must consider a number of factors when deciding
whether intubation is needed, including the patient's respiratory status, the pathologic
process and likelihood of deterioration, patient age and comorbidities, the need for
transfer to another facility, and available resources.

Whenever possible, and particularly with patients suffering from terminal disease, the
clinician should try to determine the patient's wishes regarding resuscitation (eg,
intubation) either by asking the patient directly (assuming the patient retains capacity) or
inquiring about an advanced directive (eg, "do not resuscitate" order). (See "Palliative care
for adults in the ED: Concepts, presenting complaints, and symptom management".)

In cases where the need for a definitive airway is not immediately clear, a simple
assessment consisting of three basic questions can distinguish patients requiring
intubation from those who can be observed [1]. An affirmative answer to any of the
following questions identifies the need for intubation in nearly all emergency scenarios (
algorithm 1):
● Is patency or protection of the airway at risk?
- Page 2 of 9 -
The decision to intubate
● Is oxygenation or ventilation failing?
● Is a need for intubation anticipated (ie, what is the expected clinical course)?

IS PATENCY OR PROTECTION OF THE AIRWAY AT RISK?

A patient who can phonate clearly and answer questions appropriately demonstrates
airway patency, adequate ventilation, vocal cord function, and cerebral perfusion with
oxygenated blood. The level of alertness needed to maintain airway tone is the same
required to maintain brisk protective reflexes to prevent aspiration of oral and gastric
fluids. Aspiration of gastric contents can cause pneumonitis and result in prolonged
mechanical ventilation [2,3].

The loss of protective airway reflexes mandates tracheal intubation. Traditional teaching
promoted the presence of a gag reflex as evidence that protective reflexes were intact and
aspiration would not occur. This is misleading and unfounded. The gag mechanism does
not contribute to laryngeal closure and airway protection, and it has little correlation with
the Glasgow Coma Scale (GCS). Furthermore, a sizable segment of the normal adult
population lacks a gag reflex.

The ability to phonate and swallow secretions is a more reliable sign of the patient's
capacity for airway protection than the gag reflex. While this concept has not been
subjected to rigorous scientific evaluation, swallowing represents a higher level of
neurologic complexity and more accurately represents a patient's ability to protect against
aspiration. A patient with pooling secretions, unable to swallow, requires intubation.

Pulmonary gas exchange requires an unobstructed oropharyngeal inlet, which is

maintained in awake patients by the upper airway musculature. An obstructed oropharynx
makes any attempt to supply supplemental oxygen or assist ventilation difficult.

Basic airway maneuvers, such as repositioning the patient's head with a jaw-thrust or chin-
lift, or placement of oropharyngeal and nasopharyngeal airways can bypass flaccid,
redundant upper airway tissue and provide an unobstructed passageway to the laryngeal
inlet and trachea. In general, patients who require an oral airway and tolerate its
placement need intubation for airway protection. (See "Basic airway management in
adults".)

- Page 3 of 9 -
The decision to intubate

IS OXYGENATION OR VENTILATION FAILING?

Human tissues depend on oxygen for cellular respiration. While anaerobic metabolism can
maintain function for a short time in tissues such as skeletal muscle, most specialized
tissues, especially neuronal and myocardial tissue, depend on oxygen and will sustain
irreversible damage within a few minutes without an adequate supply of oxygenated
blood. The inability to oxygenate despite supplemental oxygen poses an immediate life
threat and, with rare exceptions, mandates intubation.

Advances in noninvasive positive-pressure ventilation (NIPPV) have modified the approach

to hypoxic patients with acute cardiogenic pulmonary edema and acute exacerbations of
chronic obstructive pulmonary disease (COPD). Often, NIPPV enables these patients to
avoid intubation during the acute phase of their illness, but its use is limited to alert
patients capable of protecting their airway against aspiration. The role of NIPPV in patients
with other causes of acute respiratory distress remains unclear. NIPPV should not replace
tracheal intubation in patients with severe respiratory distress or those who suffer from
disease states that are unlikely to reverse quickly. (See "Noninvasive ventilation in adults
with acute respiratory failure: Benefits and contraindications".)

Clinicians assess the patient's oxygenation using clinical criteria and oxygen saturation
measurements. Clinically, hypoxic patients act restless and agitated, and with severe
hypoxemia can appear cyanotic. As hypoxia worsens, confusion, somnolence, and
obtundation occur. Patients are often tachycardic with mild to moderate degrees of
hypoxia but exhibit profound bradycardia or agonal, non-perfusing rhythms with critically
low oxygen saturations. Pulse oximetry provides an accurate estimate of arterial oxygen
tension but can be unreliable when peripheral perfusion is compromised [4,5]. (See "Pulse
oximetry" and "Measures of oxygenation and mechanisms of hypoxemia".)

Clinicians should not rely on arterial blood gases (ABGs) in the emergency setting to
determine the immediate need for intubation. ABGs provide little information not already
apparent from clinical presentation and pulse oximetry, and they can be misleading. As an
example, an "unimpressive" ABG in a severe asthmatic may persuade the emergency
clinician to postpone intubation when, clinically, the patient is failing. Waiting in such
circumstances can be disastrous, creating an immediate need for intubation when the
patient suddenly becomes apneic.

Removal of carbon dioxide (CO2), the major waste product of cellular metabolism, depends
- Page 4 of 9 -
The decision to intubate

on proper lung function and ventilation. Impaired ventilation from airway obstruction,
muscular weakness, or drug-induced hypopnea results in impaired CO2 elimination.
Clinicians can generally gauge a patient's ventilations by observing respirations and mental
status. Capnography provides a simple means of continuously measuring end-tidal CO2 to
assess the adequacy of ventilation, when this is not clear, or to monitor the response to
treatment. (See "Carbon dioxide monitoring (capnography)".)

Patients with chronic ventilatory failure (eg, COPD) can acclimate to the altered gas
tensions of impaired ventilation if decompensation is gradual, but acute CO2 retention can
lead to altered mental status and respiratory acidosis. Patients with inadequate ventilation
require intubation, unless the cause is immediately reversible (eg, opioid overdose). In
select patients with acute exacerbations of COPD, the use of continuous positive airway
pressure (CPAP) or bilevel positive airway pressure (BLPAP) may obviate tracheal intubation
[6,7]. (See "Noninvasive ventilation in adults with acute respiratory failure: Benefits and
contraindications".)

Despite advances in NIPPV, many patients, especially malnourished or dehydrated

patients, fail trials of CPAP or BLPAP. Other patients present too ill for such measures to be
effective, and intubation is needed. Continual reevaluation of patients treated with CPAP or
BLPAP is required to detect clinical deterioration and provide definitive airway
management if needed.

IS A NEED FOR INTUBATION ANTICIPATED?

Failure to maintain airway protection, oxygenation, or ventilation comprises

straightforward criteria for intubation that encompasses the majority of emergency airway
cases. However, some emergency patients require intubation even though there is no
immediate threat to oxygenation or airway patency.

Often, acutely ill or injured patients initially appear awake and alert, speak clearly in full
sentences, demonstrate adequate oxygen saturation, and appear not to require immediate
airway management. Nevertheless, the natural progression of their disease would result in
airway compromise or an inability to maintain oxygenation if the emergency clinician were
not to intervene. By pursuing early, aggressive airway management, emergency clinicians
avoid unplanned, hurried, or salvage airway situations, when equipment, medications, and
personnel may not be ready. It is preferable to err on the side of caution and place a

- Page 5 of 9 -
The decision to intubate

definitive airway if the potential for airway compromise exists.

As an example, an older adult patient with pneumonia and severe sepsis who is somnolent
but arousable, with adequate oxygen saturation on supplemental oxygen, may not initially
meet any of the criteria described above for tracheal intubation. Nevertheless, the patient's
anticipated clinical course is a decline in respiratory function. During the resuscitative
phase of sepsis management, the patient will receive intravenous isotonic fluids,
antibiotics, and possibly blood products. This fluid load, coupled with a diffuse capillary
leak syndrome, will increase pulmonary interstitial edema and likely lead to respiratory
failure with worsening hypoxemia and acidemia.

As another example, the burn victim with evidence of significant smoke inhalation likely
requires immediate intubation (or at least direct or fiberoptic examination of the upper
airway structures and glottis) because the projected clinical course is complete airway
obstruction, although the patient may initially manifest no sign of airway compromise. (See
"Inhalation injury from heat, smoke, or chemical irritants".)

Patients with the potential for respiratory decompensation who must be transported out
of the emergency department often require intubation. Regardless of whether transport is
to the radiology department or to another institution for specialized care, it is better to
secure the airway preemptively than to face an emergency unplanned airway in an
unfavorable setting, such as a computed tomography scanner or the back of an
ambulance. For trauma patients, intubation may be indicated before transport if the
likelihood of deterioration is high based on mechanism, injuries discovered on primary and
secondary surveys, and initial hemodynamics.

No guidelines or algorithms exist for this aspect of airway management, and there is no
way to anticipate every possible scenario in which preemptive intubation is needed. A
careful clinical assessment, including pulse oximetry (and often capnography), vital signs,
the patient's mental and respiratory status, the patient's comorbidities and response to the
acute threat, and a knowledge of the natural history of the condition with which the
patient presents all guide the need for preemptive intubation. If there is any significant
concern that a patient's deterioration will ultimately threaten the airway or make
intubation more difficult, early intubation is indicated.

APPROACH TO THE PATIENT

- Page 6 of 9 -
The decision to intubate

When the patient is not comatose or in extremis, emergency clinicians assess the patient
by asking three questions:
● Is patency or protection of the airway at risk?
● Is oxygenation or ventilation failing?
● Is a need for intubation anticipated (ie, what is the expected clinical course)?

The quickest test of airway patency and maintenance is to listen to the patient's speech.
Clear, coherent speech is a good indication of a patent and protected airway and a
reassuring sign that the airway is not in imminent danger.

If the patient is unable to phonate or his speech sounds altered, the clinician performs a
rapid investigation for upper airway obstruction. A jaw-thrust and chin-lift, with cervical
spine immobilization if indicated, is the first maneuver, followed by inspection of the
oropharynx for solid or liquid material that can be removed or suctioned. The neck is
inspected and palpated for fixed or expanding masses, laryngeal fracture, and crepitus.
Stridor is a foreboding sign indicating impending airway occlusion, and immediate
intubation is required. If these maneuvers do not identify the problem and the patient
remains unable to phonate and protect his airway, intubation is performed. As part of the
airway examination, clinicians assess whether a difficult airway exists. (See "Approach to
the difficult airway in adults for emergency medicine and critical care".)

Assessment of oxygenation and ventilation status is predominantly clinical. Hypopnea,

poor chest excursion, agitation or somnolence, and low oxygen saturation by pulse
oximetry generally provide all the data required. Capnography can provide important
information about ventilation, respiratory status, and response to treatment. (See "Pulse
oximetry" and "Carbon dioxide monitoring (capnography)".)

Overall patient condition may dictate intubation, even if no specific criteria are met. All
potentially unstable patients requiring prolonged emergency department evaluation or
transport to other facilities are candidates for early airway management. This anticipatory
step provides safer patient care because it helps to reduce the likelihood of a chaotic
"crash" intubation.

SUMMARY AND RECOMMENDATIONS

● Approach to deciding to intubate – When the need for intubation is unclear,

emergency clinicians assess the patient by asking three questions. An algorithm
- Page 7 of 9 -
The decision to intubate

incorporating these questions is provided ( algorithm 1). An affirmative answer to

any of the following questions identifies the need for intubation in nearly all
emergency scenarios (see 'Deciding to intubate: Three-question assessment' above):

• Is patency or protection of the airway at risk?

• Is oxygenation or ventilation failing?
• Is a need for intubation anticipated (ie, what is the expected clinical course)?
● Assessing airway protection – The gag reflex has no role in determining the need
for intubation or the patient's ability to protect their airway. The gag mechanism does
not contribute to laryngeal closure and airway protection, and a sizable segment of
the normal adult population lacks a gag reflex. The ability to swallow secretions is a
more reliable sign of the patient's capacity for airway protection than the gag reflex.
(See 'Is patency or protection of the airway at risk?' above.)
● Assessing oxygenation and ventilation – Assess the patient's oxygenation using
clinical criteria and oxygen saturation measurements. Clinicians can generally gauge
a patient's ventilations by observing respirations and mental status. Capnography
provides a simple means of continuously measuring end-tidal carbon dioxide to
assess the adequacy of ventilation (when unclear) or to monitor the response to
treatment. Clinicians should not rely on arterial blood gases (ABGs) in the emergency
setting to determine the immediate need for intubation. (See 'Is oxygenation or
ventilation failing?' above.)

Noninvasive positive-pressure ventilation (NIPPV) often enables patients with acute

cardiogenic pulmonary edema and acute exacerbations of chronic obstructive
pulmonary disease (COPD) to avoid intubation acutely, but its use is limited to alert
patients capable of protecting their airway against aspiration. NIPPV should not
supplant intubation for patients with severe respiratory distress requiring immediate
tracheal intubation. (See "Noninvasive ventilation in adults with acute respiratory
failure: Benefits and contraindications".)
● Anticipating need for intubation – Despite the absence of overt signs of respiratory
distress, some patients need early intubation because of their anticipated clinical
course, particularly the possibility of respiratory decompensation when outside the
emergency department or the progression of upper airway obstruction. (See 'Is a
need for intubation anticipated?' above.)

REFERENCES
- Page 8 of 9 -
The decision to intubate

1. Brown 3rd CA. The decision to intubate. In: The Walls Manual of Emergency Airway Ma
nagement, 6th ed, Brown 3rd CA, Sakles JC, Mick NW, Mosier JM, Braude DA (Eds), Wolt
ers Kluwer, Philadelphia 2023.
2. Christ A, Arranto CA, Schindler C, et al. Incidence, risk factors, and outcome of
aspiration pneumonitis in ICU overdose patients. Intensive Care Med 2006; 32:1423.
3. Miller CD, Rebuck JA, Ahern JW, Rogers FB. Daily evaluation of macroaspiration in the
critically ill post-trauma patient. Curr Surg 2005; 62:504.
4. Hummler HD, Engelmann A, Pohlandt F, et al. Decreased accuracy of pulse oximetry
measurements during low perfusion caused by sepsis: Is the perfusion index of any
value? Intensive Care Med 2006; 32:1428.
5. Talke P, Stapelfeldt C. Effect of peripheral vasoconstriction on pulse oximetry. J Clin
Monit Comput 2006; 20:305.
6. Williams TA, Finn J, Perkins GD, Jacobs IG. Prehospital continuous positive airway
pressure for acute respiratory failure: a systematic review and meta-analysis. Prehosp
Emerg Care 2013; 17:261.
7. Vital FM, Ladeira MT, Atallah AN. Non-invasive positive pressure ventilation (CPAP or
bilevel NPPV) for cardiogenic pulmonary oedema. Cochrane Database Syst Rev 2013;
:CD005351.

Topic 268 Version 17.0

© 2024 UpToDate, Inc. All rights reserved.

- Page 9 of 9 -